Child Neurology Residency Program

Deadline for application to your program (if applicable): Contact SFMatch
Duration of appointment: 3 years
Other sites of training: Childrens Hospital Los Angeles
Postgraduate training required (1,2,3 years): 2 years
US Citizenship required: NO

Director of training program: Wendy G. Mitchell, M.D.
Phone: (323) 361-2471
FAX: (323) 361-1109
E-mail: wmitchell@chla.usc.edu
Address: Childrens Hospital Los Angeles,
Division of Pediatric Neurology
4650 Sunset Blvd., M/S #82
Los Angeles, CA 90027

Program Coordinator: Kathleen Hill
Phone: (323) 361-4575
E-mail: khill@chla.usc.edu

Description of fellowship:

1. To train Child Neurology Residents in comprehensive diagnosis and management of both common and rare neurological conditions affecting neonates, children and adolescents. Although all clinical care is supervised by child neurology attendings, it is expected that the Child Neurology Resident will become progressively more capable of independent decision making as training progresses, ultimately able to provide comprehensive neurologic care of very complex, critically ill children.
2. To train Child Neurology Resident in clinical adult neurology, through rotations at adult institutions, primarily LAC-USC and University Hospital. While it is recognized that Child Neurology Resident will be Board Certified in Neurology and fully trained in basic diagnostic and therapeutic interventions in adults, it is not expected that expertise will match that of a fully committed Adult Neurologist. However, by completion of the residency, the Child Neurology Resident must be capable of providing comprehensive adult neurological care, given the reality that many will practice in settings which require cross coverage of adult neurological patients.
3. To train Child Neurology Resident in basic neurological science including but not limited to neurophysiology, neuropharmacology, neuroanatomy, neuroendocrinology, neuropathology and neurogenetics.
4. To train Child Neurology Resident in specific skills needed in the practice of neurology, including, but not limited to clinical electrophysiology (EEG, EMG, NCVs, evoked potential studies), neuroradiology, neuropathology, psychiatry, neuroopthalmology. Training in use of evoked potentials and electrophysiologic techniques in the OR is available on an elective basis.
5. To train Child Neurology Resident in the appropriate management and application of ancillary therapies such as pediatric neurorehabilitation, neuropsychological and psychometric testing, physical therapy, occupational therapy, speech therapy, behavior modification.
6. To have the Child Neurology Resident understand the ethical issues involved in the care of pediatric patients, including end of life issues, termination of support in severely brain injured individuals, and choices regarding palliative care.
7. To train the Child neurology resident in normal, variant normal and abnormal child development.
8. To impart research skills including, but not necessarily limited to clinical research design, data collection, biostatistical analysis, presentation at meetings, and manuscript preparation. To facilitate learning bench research techniques when there is particular interest.
9. To impart teaching skills, including the ability to teach in a clinical setting, give seminars, lectures to colleagues and trainees, and teach community physicians. To assist the Child Neurology Resident in preparing teaching materials on basic neurologic subjects.
10. To train Child Neurology Resident in use of community resources, particularly for handicapped children and adolescents, including, but not limited to schools, Regional Centers, public programs for supportive care and therapy, and community voluntary organizations.
11. To have the Child neurology resident understand how health care financing impacts upon both the practice of child neurology and upon resources and services available for our patients, and to have them learn skills to negotiate this increasingly challenging system. The Child neurology resident will learn to informally assess cost-effectiveness of various modalities of care, particularly to be able to decide between various options.
12. To have the child neurology resident develop exceptionally good communication skills, both with patients, parents, hospital staff and colleagues in and out of the hospital. This includes ability to communicate back to referring physicians and agencies in succinct written or dictated form.
13. To encourage community service by encouraging the Child Neurology Resident to become familiar with and, when possible, involved in programs such as the Epilepsy Foundation, Muscular Dystrophy Association, Tourette Syndrome Association, and other parent or community run groups.

First year:
Most of the first year is devoted to learning the clinical diagnostic and management techniques, including the detailed neurological exam on patients of all ages and levels of function, which are core to child and adult neurology, and the basic neuroscience which supports clinical neurology. Although exact distribution of rotations will vary, in general, Child Neurology Resident spends approximately 5-6 months on clinical Child Neurology rotations, and approximately 5-6 months on Adult Neurology rotations. 1-2 months are set aside for elective/selective, from which vacation is taken. Child Neurology Resident attends teaching clinics (seeing attendings' patients) three half-day sessions per week during Child Neurology rotations, and has a ½ day continuity clinic throughout the year. Child Neurology Resident will attend neuroscience conferences at CHLA weekly, when based at CHLA, and will attend neuroscience teaching sessions at USC weekly throughout the year ("neuroschool"), as well as other basic and clinical conferences.

Clinical goals in the first year in Child Neurology are to become proficient in the diagnosis and management of most inpatients and outpatients seen by the Child Neurology service. All patient care at CHLA is directly supervised by Child Neurology attendings, including patients scheduled in the Child Neurology Residents' continuity clinics. This includes a comprehensive understanding of the uses of neurodiagnostic tests, including but not limited to electrophysiological and neuroradiological techniques, metabolic tests, muscle biopsy, and Tensilon testing. Child Neurology Resident must be able to interact with pediatric services in both role of specialty physician and consultant. Child Neurology Resident must have an understanding of the uses of consultation from and interaction with other associated services, including, but not limited to neuroopthalmology, neurosurgery, neurooncology, pediatric rehabilitation, medical genetics, pediatric orthopedics, and child psychiatry. Child Neurology Resident will develop a basic understanding of the uses of psychometric and neuropsychological testing in child neurology. Clinical goals in the first year in Adult Neurology is to become proficient in the examination, use of diagnostic tools, and basic management of adult neurological inpatients, including moderately complex management of coexisting internal medicine conditions in neurological patients. Child Neurology Resident will be expected to provide supervision and teaching of fourth year medical students and informal teaching of pediatric housestaff. Child Neurology Resident will prepare case presentations and other material for neuroscience conference when on service at CHLA (grand rounds). Child Neurology Resident will be encouraged to begin a clinical research project under direction and supervision of a faculty member. Child Neurology Resident will be expected to provide adult neurological inpatient care and consultation at a comparable level to a first year adult neurology resident.

Child neurology resident will begin to understand health care financing system well enough to help direct patients and families in handling the increasingly complex system of authorizations, TARS, etc. The Child neurology resident will have a basic understanding of the costs of various care options.

Child Neurology Resident will be expected to develop expertise in the evaluation and management of the following groups of diagnoses, including the appropriate use of diagnostic tests and interpretation of results, use of medications, referral to consultants, and use of appropriate non-medical community resources:

Paroxysmal disorders:
Child Neurology Resident will understand and become adept at the important aspects of diagnosis including history, physical and neurological examination, use of laboratory testing, and interpretation of results of electrophysiological testing such as EEG, EKG, neuroimaging. At this level, Child Neurology Resident will not be expected to be able to provide direct reading of EEG or neuroimaging. However, they will be expected to review their own patients' neuroimaging studies with the attending and neuroradiologist, and will be expected to review their own patients' EEGs, without providing formal dictated reports.
Including but not limited to:
Symptomatic seizures (febrile, other)
Epilepsy, with particular emphasis on conditions specific to childhood
Neonatal seizures
Infantile Spasms
Age-specific epilepsies such as childhood absence, benign focal epilepsies, JME Symptomatic secondary epilepsies
Genetic syndromes such as tuberous sclerosis, malformations, Angelman's syndrome, Rett Syndrome, progressive myoclonic epilepsies Degenerative diseases with epilepsy as a major feature
Syncope, including differential diagnosis and distinction from seizures
Breath holding spells

Developmental disorders:
Child Neurology Resident will understand and become adept at appropriate diagnostic and evaluation techniques which apply to the following clinical problems, will be able to select appropriate diagnostic laboratory tests, and interpret results. Child neurology resident will be adept and interpretation of various patterns of both normal, variants of normal, and abnormal development, differentiating "delayed" from abnormal patterns of development. Child Neurology Resident will understand the uses of psychometric and neuropsychological testing, but is not expected to be able to interpret test data independent of the psychologist's reports.
Including but not limited to:
Mental retardation, whether of diagnosable or non-specific cause, including the common brain malformation syndromes, chromosomal syndromes, dysmorphologic syndromes
Cerebral palsy and related disorders
Autism and related disorders
Neurodegenerative diseases
Learning and language disabilities
Attention deficit disorder

Neuromuscular disorders:
Child Neurology Resident will be adept at clinical examination, differential diagnosis, laboratory evaluation, understanding of the uses and interpretation of results of specialized testing such as EMG, NCV, muscle biopsy (although not expected to be able to perform these tests at this level of training). Child neurology resident will understand the uses of DNA diagnostic testing in neuromuscular disorders. Child Neurology Resident will understand treatment and management techniques appropriate to neuromuscular disorders.
Including but not limited to:
Muscular dystrophies
Acquired and congenital myopathies
Acquired and genetic neuropathies
Guillain-Barre syndrome
Mitochondrial disorders
Myotonic dystrophy (congenital and childhood onset forms)
Spinal muscular atrophy
Myasthenia gravis

Tumors of the CNS:
Child Neurology Resident will be adept at diagnosis and neurological management of childhood brain and spinal cord tumors, interacting with neurosurgeons, oncologists, neuroradiologists, neuropathologists. Child Neurology Resident will gain basic understanding and familiarity with the neuroimaging characteristics of various childhood brain tumors, the neuropathology of common childhood brain tumors. Child Neurology Resident is expected to gain some familiarity with chemotherapy and radiation therapy of childhood brain tumors in a generic sense (i.e. which tumor types are treated with each), but is not expected to know specific protocols. The Child Neurology Resident is expected to be familiar with the neurological complications, both acute and long term, of chemotherapy and radiation therapy.

Neurological emergencies:
Child Neurology Resident is expected to become adept at diagnosis and management of common neurological emergencies in children presenting to emergency room, as inpatients, and in clinic, including, but not limited to:
Status epilepticus and acute seizures
Altered mental status, including encephalopathies, intoxications
Weakness (diffuse or focal), gait disturbance, myelopathy, Guillain-Barre, etc
Acute ataxias
Neurological aspects of acute hypoxic-ischemic encephalopathies including drowning, SIDS
Neurologic infections including suspected or proven encephalitis, meningitis, abscess, cysticercosis, etc.
Child Neurology Resident is expected to be familiar with the neurologic aspects of child abuse and neglect, including inflicted injuries and " shaken baby syndrome".
Child Neurology Resident is expected to be able to provide diagnostic and consultative management in selected neurotrauma, acutely increased intracranial pressure, and mass lesions, interacting with appropriate other specialties such as neurosurgery and ICU.
Child Neurology Resident will be able to perform examination for brain death (although will not be able to make formal determination of brain death without direct input from attending).

Movement disorders:
Child Neurology Resident will be expected to be able to recognize, provide diagnostic evaluation, and basic treatment of childhood movement disorders including but not limited to:
Tic disorders
Tourette Syndrome
Choreoathetosis
Dystonias

Headache and migraine:
Child Neurology Resident will be expected to be familiar with various types of headache and migraine disorders in children and adolescents, including understanding the differential diagnosis, evaluation, pharmacological and non-pharmacological treatment.

Neurological aspects of rehabilitation:
Child Neurology Resident will be able to provide comprehensive care of pediatric acute neurorehabilitation patients including interaction with appropriate specialists and therapists. Diagnostic groups include but are not limited to:
Closed head injury
Post-infectious neurological dysfunction (encephalopathies, encephalitis, meningitis, etc)
Hypoxic-ischemic encephalopathies, such as drowning, SIDS, post-cardiac arrest.
Post-operative neurosurgical patients requiring neurorehab including brain tumor patients.
Childhood stroke
Neurological aspects of acute rehabilitation of child with neuromuscular disease, recent orthopedic procedures, etc.

Childhood stroke:
Child Neurology Resident will be able to provide comprehensive evaluation, appropriate interventions and interact with associated services such as rheumatology, neurosurgery, neuroradiology, hematology and coagulation disorders for children with cerbrovascular disease including but not limited to:
Ischemic stroke
Hypercoagulable states
Hemorrhagic stroke
Cerebral vasculitis

Second year:
In the second year, the Child Neurology Resident will continue to gain expertise in clinical child neurology and adult neurology. Although rotation schedules will vary, in general, the Child Neurology Resident spends approximately 4-5 months on clinical child neurology rotations at CHLA and 4-5 months on adult neurology rotations at LAC-USC and/or the University Hospital. During the rotations on adult neurology services, they will function as a junior resident. Rotations will include adult outpatient specialty neurology clinics during neuromuscular, epilepsy, movement disorder and/or MS rotations. Two to four months are spent on elective/selective rotations. At least one month should be devoted to clinical neurophysiology (EEG), and one to basic EMG/NCV (adult neuromuscular rotation). Selective time in neuroradiology and neuropathology is strongly encouraged. Selective month in child psychiatry is required during either second or third year. Child Neurology Resident will continue to have a ½ day per week continuity child neurology clinic at CHLA for the entire year, and will be more independent in management of these patients, although always under supervision of an attending. Second year Child Neurology Residents are expected to take an active role in clinical teaching of fourth year students and pediatric residents and prepare topic-oriented conferences for neurology grand rounds. They are strongly encouraged to begin or complete a clinical research project, with the goal of presenting at one of the National neurology, child neurology or epilepsy meetings (AAN, CNS or AES) in their second year. Basic science knowledge base will be expanded by continued participation in conferences ("neuroschool") at USC.

In addition to expanding clinical expertise in the areas listed under first year, the Child Neurology Resident is expected to gain expertise in evaluation and management of more complex or uncommon problems in child neurology. Examples include:

Neurogenetic/neurodegenerative diseases:
Child Neurology Resident will be able to evaluate a child with suspected neurogenetic disease, be familiar with differential diagnosis, appropriate laboratory evaluation, and interpretation of results of evaluation. Child Neurology Resident will be familiar with prognosis, and be able to appropriately counsel family of child with diagnosed neurogenetic diseases. Child Neurology Resident will be familiar with the biology and biochemistry of neurogenetic diseases. Examples include, but are not limited to:
Inborn errors of metabolism such as non-ketotic hyperglycinemia, homocysteinuria, methylmalonic aciduria, PKU
Lysosomal storage diseases such as Tay-Sachs, Krabbe, MLD, etc
Peroxisomal diseases such as ALD, neonatal ALD, Zellweger's syndrome, Refsum disease, etc.
Mitochondrial diseases and conditions suspected to be due to mitochondrial dysfunction including Leigh Syndrome, Kearn-Sayer Syndrome, mitochondrial cytopathies.
Disorders of metal metabolism such as Wilson Disease, Menke Syndrome

Complex and intractable epilepsy:
Child Neurology Resident will gain additional knowledge and expertise in evaluation and treatment of the intractable epilepsy patient. This includes familiarity with and expertise in use of:
VideoEEG for evaluation, differential diagnosis, localization of epileptic discharges
Ketogenic diet
Vagal nerve stimulator
Epilepsy surgery, including selection of appropriate candidates for comprehensive evaluation New anticonvulsants including experimental and protocol drugs.

Developmental disorders, learning disabilities, autism, ADHD
Child Neurology Resident will gain additional knowledge and expertise in evaluation and management of complex learning and language disorders, including in the interpretation of psychometric and neuropsychological testing reports. The Child neurology resident will be able to do simple assessment of cognitive and academic skills in the context of routine office care.

Clinical neurophysiology (EEG, Evoked potentials, nerve conduction studies, EMG)
During selective rotations, Child Neurology Resident will become familiar with the technical aspects of performance of and interpretation of the following procedures:
Routine, sleep deprived and specialized EEG, Video EEG, including brain death recordings
Nerve conduction studies including repetitive stimulation
Needle EMG
Visual, brain stem and somatosensory evoked potentials for neurodiagnostic uses.

Behavioral and psychiatric disorders in childhood
Child Neurology Resident will learn to evaluate and collaboratively manage selected behavioral disorders which commonly present neurologically, including but not limited to:
Pseudoseizures
Somatoform pain disorders, reflex neurovascular dystrophy
Episodic conduct disorders
Psychiatric disorders presenting in neurologic patients and/or mimicking neurologic disease
Delirium

Brain tumor:
The Child Neurology Resident should gain greater expertise in the specifics of management of malignant brain tumors, including knowledge of commonly used chemotherapy agents and protocols, and rationale for various modalities of therapy including radiation, gamma knife, and bone marrow transplant. Child Neurology Resident is not expected to either administer these therapies or know specifics of dosage and administration, but should be familiar with the common neurological and systemic adverse effects of therapy, as well as long term sequelae.

Neurology of systemic illness:
The Child Neurology Resident should be able to competently consult and assist in managing neurologic complications of complex pediatric systemic illnesses including but not limited to:
Neurological complications of transplant patients
Renal disease and dialysis
Rheumatological diseases
Severe acute systemic diseases and organ failure necessitating intensive care
Neurological complications of pediatric HIV/AIDS and it's treatment
Neurological complications of cancer and its treatment, including chemotherapy induced central and peripheral nervous system diseases.

Third year:
In the third year of training the Child Neurology Resident will spend 2-3 months on the clinical child neurology inpatient service at CHLA, serving as a senior resident, with responsibility for coordinating the other residents and students, in addition to seeing patients. Child Neurology Resident will spend 1-3 months on Adult Neurology at LAC-USC or University Hospital in the capacity of "ward senior" at LAC-USC or on one of the specialty adult neurology services at University Hospital. Child Neurology Resident will continue to have ½ day/week in continuity clinic at CHLA. Child Neurology Resident will be expected to provide clinical teaching to fourth year students, pediatric residents, and junior Child Neurology Residents and adult neurology residents at CHLA. In addition, third year Child Neurology Resident will be expected to prepare formal lectures and teaching conferences for pediatric housestaff and others at CHLA. When on "selective" rotations based at CHLA, the child neurology resident will be expected to prepare weekly brief lectures for the students on basic neurological topics.

The third year is otherwise spent is selective/elective rotations. At least 2-3 months further training in electrophysiology is strongly encouraged, during which Child Neurology Resident reads EEGs, evoked potentials, and VEEGs under supervision of attending. Further selective time in neuroradiology and neuropathology is encouraged. The remaining time is dependent upon specific needs and goals of the resident. One month in child psychiatry if not done in second year (consult-liaison service) will be completed. Elective months in medical genetics, pediatric rehabilitation, neurooncology, neuroophthalmology are encouraged, some of which are best arranged "in tandem" with EEG, neuropathology or neuroradiology, as they are not full time. Rotation with pediatric development program, neuropsychology, pediatric neurosurgery or inpatient child psychiatry can be arranged. For Child Neurology Resident with particular interest, further training in EMG and NCV studies can be obtained at LACUSC or elsewhere. For the Child Neurology Resident who has interests in developing a basic science research career, up to four months of elective time may be spent in a lab, either with a CHLA or USC faculty member.

All Child Neurology Residents are strongly encouraged to plan and execute a clinical research protocol under a faculty member's direction. Brief classroom training in biostatistics and research design is available through the CHLA Research Institute. Attendance at the annual 2 week course in clinical research methodology for new fellows will be arranged (generally the second ½ of July). For child neurology residents planning a career including clinical research, arrangements can be made to complete a biostatistics course at USC.

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